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NP T1
Nursing Process Test 1
| Question | Answer |
|---|---|
| Five Steps of the nursing process | Assessment; Diagnosis; Planning; Implementation; and Evaluation |
| Step 1: Assessment | Gathering Information |
| Step 2: Diagnosis | Identify the Problem |
| Step 3: Planning | Decide what actions will be taken (Goal) |
| Step 4: Implementation | test your Plan (Goal) |
| Step 5: Evaluation | Evaluate the solution |
| Nursing Assessment | Systematin and Continuous collection and analasys of information about a client |
| Objective Data | Data that is measurable and/or observable |
| Subjective Data | Opinions, Judgements, Client Statements |
| Data Collection Must Be? | Factual, unbiased, impartial and updated continuously |
| 5 Assessment Observation tools | Visual/Sight; Touch; Hearing; Smell; Taste |
| Nursing Diagnosis | Problem is in the scope of nursing, treat problem w/o consulting a physician |
| Medical Diagnosis | Problem requires medical treatment, Collaborative problem given by doctor |
| The four conclusions that are possible for diagnosis | 1. pt has no problem; 2. pt might have a problem; 3. pt is at risk for a problem; 4. pt has a problem |
| Components of nursing history | Biographical data; reason for coming to the facility; recent health history; important medical history; pertinent psychosocial information; Activities of Daily Life (ADL) |
| Types of Lung Sounds | Crackles, Rhonchi - Deep sound; Wheezes - Whistles; Stridor - Shrill harsh sounds |
| Factors that influence disease | Acute - Sudden development and quick health; Chronic - Continues for a long time; Acuity - Level of severity; Complication - unexpected event; Primary - independent, by itself; Secondary - Direct result or dependent on another disease |
| Bodies response to disease | Signs and Symptoms |
| Signs and Symptoms of disease | Anorexia - lack of appetite; Cough; Diarrhea; Edema; Fatigue; Hemorage; Cyanosis; Dyspnea - SOB; Emesis; Jaundice; Malaise - discomfort; Pallor - Paleness; Pyrexia - Fever |
| Skin Color Variations | Erythema - Redness; Cyanosis - Bluish-gray around mucous membranes; Jaundice - Yellow; pallor - lack of color |
| Characteristics of the nursing process | Systematic; client-oriented; goal oriented; continuous; dynamic |
| What do you do when you have made an error in documentation? | Single line through it; Parenthesis around error; word ERROR and initials above error |
| Short term goal? | A goal to be achieved w/in a day or so |
| Long Term Goal? | A goal to be achieved in a week or more |
| Independent Actions? | Actions that the nurse can do with no one elses input or assistance |
| Dependent Actions? | Physician ordered, Must be followed explicitely |
| Interdependent Action | Actions performed collaboratively with other care professionals |
| Why do we write Nursing Care Plans? | To learn the thinking proess |
| Nursing Care Plans Should Be? | Individualized to each client |
| Dx statement parts/requirements? | 3 Parts: Problem - Etiology - Signs and Symptoms; Requirement: To be clear and precise |
| What are the different types of learners? | Visual - Auditory - Kinesthetic |
| What are the domains of learning? | Cognitive - memory; Affective - Emotional; Psychomotor - Hands on |
| Types of Teaching | Formal - specific time/place, classroom setting; Informal - anywhere anytime |
| What are teaching strategies? | Techniques to promote learning |
| What are the barriers to learning? | Environmental;Sociocultural;Psychological;Physiological |
| Teaching throughout life | Children - Play;Adolescents - Peers/Role Models;Older Adults - Explanations, use normal terms |
| What are the rules for "planning" (goals)? | Client Oriented; Specific; Reasonable; measurable |
| How are Nursing Dx prioritized? | ABC - Airway; Breathing; Circulation/Then Life over Limb |
| What is critical Thinking? | A complicated mix of experience, prior information, inquiry, logic and common sense to solve a problem |
| What are the Observation Techniques? | Visual; Tactile - palpation(touch); Auditory - Auscultation(hearing); Olfactory or gustatory - Smell |
| PRN | As needed |
| A (with line above) | Before |
| AAO | Awake, Alert, Oriented |
| Abd | Abdomen |
| AEB | As Evidenced By |
| R/T | Related To |
| B/P | Blood Pressure |
| AROM | Active Range Of Motion |
| BBS | Bilateral Breath Sounds |
| BM | Bowel Movement |
| BS+*4 | Bowel Sounds Positive in all 4 Quads |
| c/o | Complaints of |
| d/i | dry and intact |
| h/o | history of |
| HR | Heart Rate |
| hx | history of |
| I&O | Intake and Output |
| IS | Incentive Spirometer |
| LOC | Level of Consciousness |
| MAE | Moves All Extremeties |
| NPO | Nothing By Mouth |
| NAD | No Apparent Distress |
| NC | Nasal cannula |
| PERRLA | Pupils equal, round reactive to light and accomodation |
| PERRL | Pupils equal, round reactive to light |
| POC | Plan of care |
| PROM | Passive Range Of Motion |
| Pt | Patient, Client |
| q | Every |
| TCDB | Turn Cough Deep Breath |
| T | Temperature |
| S/S | Signs and Symptoms |
| ROM | Range Of Motion |
| W/D | Warm and Dry |
| WNL | Within Normal Limits |
| Every entry into the care plan/assessment must have? | The time, date and your initials |
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